Citation Nr: 0032265
Decision Date: 12/11/00 Archive Date: 12/20/00
DOCKET NO. 96-38 408 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Chicago,
Illinois
THE ISSUE
Entitlement to service connection for a cervical spine
disorder manifested by degenerative joint disease and an
abnormal sagittal contour.
REPRESENTATION
Appellant represented by: Veterans of Foreign Wars of
the United States
ATTORNEY FOR THE BOARD
Nadine W. Benjamin, Counsel
INTRODUCTION
The veteran served on active duty from March 1978 to May
1995. This matter comes to the Board of Veterans' Appeals
(Board) on appeal from rating decisions by the Department of
Veterans Affairs (VA) Regional Office (RO) in Chicago,
Illinois.
In February 1999 and again in February 2000, the Board
remanded the veteran's claim to the RO for additional
development. The case has been returned to the Board and is
ready for further review.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
resolution of the veteran's appeal has been obtained by the
RO.
2. The veteran was treated during service for upper back
complaints. Her current complaints are reasonably related to
service.
CONCLUSION OF LAW
A cervical spine disorder manifested by degenerative joint
disease and an abnormal sagittal contour was incurred in
service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107
(West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Service connection may be granted if the evidence
demonstrates that a current disability resulted from an
injury or disease incurred or aggravated in active military
service, and arthritis, if manifested to a compensable degree
within the first post service year, may be presumed to have
been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113,
1131, 1137 (West 1991); 38 C.F.R. §§ 3.303(a) 23.307, 3.309
(1999).
The claimant has the burden of submitting evidence sufficient
to justify a belief by a fair and impartial individual that
the claim is well grounded or capable of substantiation. 38
U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159(a) (1997).
If the claim is well grounded, it must be shown that all
relevant facts have been properly developed and that the duty
to assist the veteran as mandated by 38 U.S.C.A. § 5107 has
been complied with. The Board finds that the claim is well
grounded.
The record shows that the veteran was treated in service for
back complaints on several occasions. In 1993, she was
treated for upper back/trapezius tightness, secondary to
workplace. On separation examination in May 1995, she
reported recurrent back pain since 1992.
The veteran underwent a VA examination in June 1995, and
complained of pain along the trapezius muscle, which occurred
once in a while. On examination, some tautness of the right
trapezius muscle was noted. Examination showed hypertrophied
muscle of the neck. It was reported that there was full
range of motion of the neck; and the diagnosis was, muscular
pain along the trapezius area, only occasional now, better
since leaving service, with no functional impediment, with
some tautness of the right trapezius muscle. Apparently, no
X-rays were taken.
The veteran was examined by VA in August 1999. The claims
file was reviewed, and the veteran's military and civilian
medical histories were noted. X-ray reports of the cervical
spine indicated that there were small anterior hypertrophic
spurs at the C5, and reversal of the normal lordotic curve.
X-rays of the lumbar spine were noted to be normal.
Examination of the lumbar spine showed that the veteran had
no scoliosis, no loss of lumbar lordosis, no abnormal
kyphosis, and no muscle spasm. Range of the motion was to 85
degrees of forward flexion; to 30 degrees of back extension;
and 35 degrees of lateral rotation, bilaterally. It was
noted that there were no complaints of pain with any motion,
and no evidence of muscle weakness. There was no tenderness.
Examination of the thoracic spine showed normal alignment
with no muscle spasm, weakness or tenderness. There was 45
degrees of rotation, right and left. The cervical spine
rotated to 90 degrees right and left with neck extension to
45 degrees and neck flexion to 45 degrees. Movements
were without pain. There was no spasm or tenderness. Range
of motion of the shoulders was noted to be full and
unrestricted with no complaints of pain. It was noted that
the veteran had no flare-ups. The examination diagnoses
were, cervical pain; thoracic pain; and lumbar pain. The
examiner opined that the examination was normal with no
objective evidence to suggest any abnormality. It was stated
that the veteran's symptoms were subjective. This opinion
was given prior to the examiner's review of the X-rays. In
an August 1999 addendum, the VA examiner noted that he had
reviewed the X-rays and that all films of the cervical spine,
thoracic spine and lumbar spine were negative for showing
evidence of degenerative changes or other bone abnormalities.
The radiographic reports showed findings of hypertrophic
spurs (arthritis) and revealed reversal of the normal
lordotic curve of the cervical spine.
The veteran underwent a VA examination in March 2000. It was
noted that the veteran complained of neck pain and
interscapular pain. The examiner stated that the claims file
had been reviewed in its entirety in preparing the report.
The veteran's military history was noted, including that the
veteran complained of upper and low back pain during the
1990's. It was noted that the veteran currently complained
of neck pain and interscapular pain. Examination showed full
range of motion of the neck. It was stated that the veteran
could put chin to chest, extend to 40 degrees, laterally
rotate to 35 degrees and laterally bend to 20 degrees. There
was no deformity and no visible atrophy. Tenderness about
the cervical spinous processes as well as the interscapular
thoracic and spinous processes as well. Shoulder range of
motion was reported to be full with no tenderness or
weakness. Motion of the lumbar spine was as follows:
extension to 20 degrees; flexion to 40 degrees; and lateral
bending to 20 degrees, without spasm. X-rays of the lumbar
spine were unremarkable. X-rays of the cervical spine showed
an abnormal sagittal contour, that is, loss of the normal
lordosis and mildly kyphotic in the mid cervical region.
Minimal spur formation was noted from the superior aspect of
the C5
posteriorly. The examiner found mild cervical degenerative
joint disease. It was reported that this could have various
origins, reflecting previous trauma incurred both in and
outside the military and any number of repetitive situations
which might increase the load on cervical disks. It was
noted that there was no documented history of an injury which
occurred while in the military.
The examiner opined that based on the evidence, there was
little to suggest that the veteran sustained injury on insult
while in the military which may have led to the acceleration
of cervical disk disease. It was noted that the veteran had
an abnormality in contour, but that there appeared to be no
specific inciting event. It was stated that therefore it was
impossible to correlate the presence of the abnormality on
radiographs with the veteran's military history. It was
reported that although the veteran had some cervical and
interscapular pain, there were no specific findings which
pointed to the presence of disk herniation or nerve re-
irritation. It was noted that the veteran did not have
atrophy, paresis, deformity or limitation in range of motion.
The Board notes that the veteran complained of neck pain in
service, and was treated for upper back complaints secondary
to workplace. She has continued to complain of upper back
problems after service. Recently, X-ray reports have
confirmed the presence of hypertrophic spurs at the C5 as
well as an abnormal sagittal contour. Cervical degenerative
joint disease has been diagnosed. It is reasonable to
conclude that the veteran's current complaints are related to
her inservice upper back problems. The Board notes that the
March 2000 VA examiner has stated that it was impossible to
correlate the presence of the spine abnormality with the
veteran's military history and that there was little to
suggest that the veteran sustained an injury or insult while
in the military which may have led to the acceleration of
cervical disk disease. However, the Board finds that
implicit in this finding is a determination that a
relationship with service cannot be entirely ruled out.
While an injury in service is not documented, the veteran was
treated for neck pain associated with the work place. It is
reasonable to find that repetitive movements associated with
the veteran's job in service could have contributed to the
current findings. Thus, with the resolution of reasonable
doubt in the favor of the veteran, the Board finds that
service connection is warranted for a cervical spine disorder
manifested by degenerative joint disease and an abnormal
sagittal contour.
ORDER
Service connection for a cervical spine disorder manifested
by degenerative joint disease and an abnormal sagittal
contour is granted.
F. JUDGE FLOWERS
Veterans Law Judge
Board of Veterans' Appeals